Historical ESWT Paradigms Are Overcome: A Narrative Review

Abstract

Extracorporeal Shock Wave Therapy (ESWT) is a conservative treatment modality with still growing interest in musculoskeletal disorders. This narrative review aims to present an overview covering 20-year development in the field of musculoskeletal ESWT. Eight historical paradigms have been identified and put under question from a current perspective: energy intensity, focus size, anesthesia, imaging, growth plates, acuteness, calcifications, and number of sessions. All paradigms as set in a historical consensus meeting in 1995 are to be revised. First, modern musculoskeletal ESWT is divided into focused and radial technology and the physical differences are about 100-fold with respect to the applied energy. Most lesions to be treated are easy to reach and clinical focusing plays a major role today. Lesion size is no longer a matter of concern. With the exception of nonunion fractures full, regional, or even local anesthesia is not helpful in musculoskeletal indications. Juvenile patients can also effectively be treated without risk of epiphyseal damage. Further research is needed to answer the question about if and which acute injuries can be managed effectively. Treatment parameters like the number of sessions are still relying on empirical data and have to be further elucidated.

Full text

Review Article
Historical ESWT Paradigms Are Overcome: A Narrative Review
Heinz Lohrer,1,2,3 Tanja Nauck,1,3 Vasileios Korakakis,4,5 and Nikos Malliaropoulos3,6,7,8,9
1European Sportscare Network (ESN), Zentrum f¨
ur Sportorthop¨
adie, Borsigstrasse 2, 65205 Wiesbaden-Nordenstadt, Germany
2Institute for Sport and Sport Sciences, Albert-Ludwigs-Universit¨
at Freiburg im Breisgau, Schwarzwaldstraße 175,
79117 Freiburg, Germany
3European SportsCare, 68 Harley Street, London W1G 7HE, UK
4Aspetar Orthopaedic and Sports Medicine Hospital, Sport City Street, P.O. Box 29222, Doha, Qatar
5Institute for Postgraduate Studies in Manual erapy, 111528 Athens, Greece
6essaloniki Sports and Exercise Medicine Clinic, Asklipiou 17, 54639 essaloniki, Greece
7National Track and Field Centre, Sports Medicine Clinic of S.E.G.A.S., Kautatzoglion Stadion, Agiou Dimitriou 100,
54636 essaloniki, Greece
8Sports Clinic, Rheumatology Department, Barts Health NHS Trust, Bancro Road, London E1 4DG, UK
9Centre for Sports and Exercise Medicine, Queen Mary, University of London, Bancro Road, London E1 4DG, UK
Correspondence should be addressed to Heinz Lohrer; heinz@heinz-lohrer.de
Received  February ; Revised  May ; Accepted  June 
Academic Editor: Giuseppe Filardo
Copyright ©  Heinz Lohrer et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Extracorporeal Shock Wave erapy (ESWT) is a conservative treatment modality with still growing interest in musculoskeletal
disorders. is narrative review aims to present an overview covering -year development in the eld of musculoskeletal ESWT.
Eight historical paradigms have been identied and put under question from a current perspective: energy intensity, focus size,
anesthesia, imaging, growth plates, acuteness, calcications, and number of sessions. All paradigms as set in a historical consensus
meeting in  are to be revised. First, modern musculoskeletal ESWT is divided into focused and radial technology and the
physical dierences are about -fold with respect to the applied energy. Most lesions to be treated are easy to reach and clinical
focusing plays a major role today. Lesion size is no longer a matter of concern. With the exception of nonunion fractures full,
regional, or even local anesthesia is not helpful in musculoskeletal indications. Juvenile patients can also eectively be treated
without risk of epiphyseal damage. Further research is needed to answer the question about if and which acute injuries can be
managed eectively. Treatment parameters like the number of sessions are still relying on empirical data and have to be further
elucidated.
1. Introduction
Explosiveeventsinnature(e.g.,lightningstroke)andtechnics
(e.g., airplanes breaking through the sound barrier) create
shock waves. In principle, these acoustic waves transmit
energy “from the point of generation to remote regions.” e
principle of this natural phenomenon has been transferred to
medical application. “Shock and pressure waves are pulses,
while ultrasound is a continuous oscillation” []. Shockwaves
are generated extracorporeally (electrohydraulic, piezoelec-
tric, or electromagnetic). e resulting energy is focused
by concentrating reectors and is noninvasively transmitted
inside the body to induce therapeutic eects at a target area.
So-called radial shockwaves have dierent physical charac-
teristics. ey are pressure waves and not real shockwaves.
Dierent tissues possess dierent acoustic impedance. At the
interface between these tissues, acoustic energy is released
and transformed into mechanical energy [].
Starting in , extracorporeal shockwaves were applied
transcutaneously for the rst time in medicine to destroy a
kidney stone in a human []. Since then, several million peo-
ple have beneted from this noninvasive method. As a result
of the high energy applied in Extracorporeal Shock Wave
Lithotripsy, much research has been performed to investigate
Hindawi Publishing Corporation
BioMed Research International
Volume 2016, Article ID 3850461, 7 pages
http://dx.doi.org/10.1155/2016/3850461

BioMed Research International
possible side eects on tissues which are penetrated by the
shockwaves on their way from the skin to the stone. By doing
this, attention was paid not only to the focus zone where
the highest energy is delivered but also to the surrounding
area where lower energy is released. In consequence both
destructive and regenerative eects were seen in bony tissues
[]. A dose-dependent eect was detected with high energy
leading to more destructive eects and lower energy leading
to more regenerative eects on the treated tissue [–]. In
the early s, extracorporeal shockwave eects on bone
and so tissues have led to indicating this treatment also
for musculoskeletal disorders [, ]. Consequently, specic
devices for musculoskeletal focused Extracorporeal Shock
Wave erapy (fESWT) were introduced into the market.
ese devices focus the shock waves to a point which is
approximately – cm apart from the application to the
skin. Compared with the urologic lithotripters which recom-
mended immersion of the patient in a water bath, this rst
generation of orthopedic devices had reduced and adjustable
energy release. Coupling to the patient’s body was performed
by ultrasound gel and aiming was realized by ultrasound [].
In a consensus meeting in , instructions were established
for the use of extracorporeal shock waves in musculoskeletal
indications []: (a) high energy only, (b) small “focus,”
(c) anesthesia, (d) imaging guided application, (e) avoiding
growth plates, (f) no acute injuries, (g) so tissue pain in
the proximity to bones (insertional tendinopathy), and (h)
tendinopathies with extraosseous calcication.
In the early s, devices featuring ballistic pressure
waves were introduced into the Extracorporeal Shock Wave
erapy (ESWT) market. ese waves are produced mechan-
ically by a compressed air driven projectile which hits the
applicator. is technology is since named radial ESWT
(rESWT). e respective devices are much cheaper, smaller,
and easier to handle. However, the maximum rESWT energy
is delivered at the applicator to skin interface and focused
shock waves peak pressure is about  times higher while
the pulse duration is  times shorter []. e clinical
eectofrESWTcouldsoonbedemonstrated[]andtoday
rESWT is a widely accepted method with comparable results
specically for supercial musculoskeletal disorders [, ].
is review paper updates the current knowledge with
respect to the historical paradigms as set in  [].
2. Materials and Methods
is narrative review presents eight dierent ESWT
paradigms which were extracted from a historical German
consensus meeting held in . We evaluated if these
paradigms are still true aer  years of further development
of the method.
Historically, most research related to musculoskeletal
ESWT literature was published in German language and
in books or journals which are not referenced in Medline.
erefore, a systematic search was judged not to be a
reasonable approach.
e bases for the current investigation are the authors’
databases, containing both historical Medline listed papers
onESWTandalsohistoricalESWTarticleswhichwere
published in German language. e content of these articles
is further reported.
For each of the eight individual paradigms, the historical
background is addressed. Developments over time and recent
perspectives to these topics were analysed also from the
authors’ literature databases.
3. Results
3.1. High Energy Only? Historically, the companies provided
the users with dierent specications of the used energy
levels,someofthemusedtheappliedenergyuxdensity
(ED), and others used the voltage (kV) led into the device
to produce the shock waves. In particular, the description of
the voltage is device depending and therefore a comparison
between dierent technologies (devices from dierent pro-
ducers) is meaningless. So the convention was made to use
ED (mJ/mm2)asthecomparableparameter.Itturnedoutthat
it is not enough to look at only one parameter. So it is no
wonder that there are many conicting publications due to
the dierent energy descriptions [, ].
Beside the well-known shock wave eect of disintegration
of concrements, a stimulation of brous tissue could be
demonstrated to occur and this dierent biologic mechanism
was dose-dependent [].
Consequently and already in the early s musculo-
skeletal ESWT was divided into “low” (.–. mJ/mm2)
and “medium” (– kV) energy applications []. Not
concordant with the former, a classication of low
(<. mJ/mm2), medium (.–. mJ/mm2), and
high (>. mJ/mm2) energy was introduced and established
[, ]. Evidence was obtained from an experimental
study, demonstrating that “energy ux densities of over
. mJ/mm should not be used clinically in the treatment of
tendon disorders” []. Initially, low energy ESWT was called
“pain therapy” and anesthesia was not considered a “conditio
sine qua non” []. Early reports demonstrated promising
results with low energy ESWT for so tissue injuries like
tennis elbow and plantar fasciitis []. Meanwhile, so
tissue indications were equally established for low energy
fESWT and also rESWT. Comparable results are published
regarding plantar fasciitis [–], Achilles [, ], and
patellar tendinopathy [, , ]. A recent systematic
review, respectively, conrms that “there is no scientic
evidence in favor of either rESWT or fESWT with respect to
treatment outcome” [].
3.2. Small “Focus” Only? Historically, ESWT was performed
with lithotripters and also the rst generation of muscu-
loskeletal ESWT devices was based on the focused tech-
nology. Respectively, maximum energy was applied to a
small area – cm below the applicator and this energy was
concentrated in an area with a diameter of – mm [].
erefore, painful syndromes originating from a larger area
were not considered as an indication for ESWT [, ]. Sim-
ilarly, radiating or referred pain syndromes without a clear
anatomic substrate were not regarded suitable for ESWT [].
At that time, the fact that relevant energy is also measur-
able peripherally to the focal zone was neglected. Accepted

BioMed Research International 
indications were nonunion fractures, plantar fasciitis, tennis
elbow, and calcic shoulder tendinopathy []. e “small
focus only” statement was held until the invention of the
radial technology [], with the maximum energy delivered
at the tip of the applicator. Due to the smaller sizes and lower
costs of the devices, rESWT has increasingly been used all
over the world. Even if the applied energy diminishes by
square relative to the penetration depth, also this method
has meanwhile clearly demonstrated its eectiveness for so
tissue injuries in level  studies [, ].
In a next step, rESWT was applied to treat more complex
musculoskeletal symptoms associated with trigger points.
e underlying mechanism of action is explained by the
concept of myofascial pain []. Recently and inspired by
traditional Chinese medicine, ESWT acupuncture has been
invented [].
3.3. (Local) Anesthesia? Anesthesia allows applying shock-
waves with higher intensities. Derived from kidney stone and
nonunion fracture experience, high energy was proposed for
orthopedic ESWT indications [, ]. Consequently, in the
early s it was suggested to adapt anesthesia (full, regional,
or local) according to the applied energy level []. As a result
of analgesia or anesthesia, several randomized controlled
studies failed to demonstrate a signicant advantage of ESWT
against sham treatment [, ]. It was in  when two
randomized controlled studies revealed that local anesthesia
at least reduces the eect of ESWT for plantar fasciitis [, ]
and this eect was only partly compensated by applying
higher energy levels under local anesthesia []. Comparable
negative local anesthesia eects were demonstrated for inser-
tional Achilles tendinopathy [].
Nowadays, (local) anesthesia is still regarded as helpful
for bone indications [] but is not recommended for so
tissue ESWT [].
Meanwhile, there is evidence from experimental research
that the pain producing eect of ESWT is responsible for
the release of neuropeptides (like substance P) initiating both
central and local trophic eects to increase metabolism in
bradytrophic tissues [, ]. It was experimentally demon-
strated that “...ESWT dose-dependently activates and sen-
sitizes primary aerent nociceptive C-bers, and that both
activation and sensitization were prevented if local anesthesia
was applied” [].
3.4. Imaging Guided Application? At the beginning of the
orthopedic shock wave era, it was generally agreed that focal
degenerative lesions within the injured tissues are responsible
for the painful syndromes and should be exactly targeted by
ESWT. erefore, visualizing aiming devices were demanded
[]. Fluoroscopy was already integrated in all urologic fESWT
devices which were used also for the initial years to treat
orthopedic injuries. However, visualization of so tissues was
not possible. In , in our center, the rst fESWT device
was installed to specically treat sport orthopedic so tissue
indications. Most importantly, it was radiation free. An inline
sonography system was incorporated in order to aim exactly
the shock waves at the structure of interest. In , this
F : Initiation of the ESWT technology to treat Olympic
athletes during the  Olympic Games in Atlanta.
machinewasavailablefortheGermanteamathletesduring
the Atlanta Olympic Games (Figure ). Even if it was not sta-
tionary and its volume, weight, and price were considerably
reduced compared with the lithotripters, transportation was
a logistic eort. erefore, really small and mobile ESWT
devices were requested []. Again, urologists took this next
step and applied the principle and the technology of an
already existing device for intracorporeal ballistic lithotripsy
to treat orthopedic so tissue indications percutaneously.
at new technology produced pressure waves and not
real shock waves, but the term radial shock wave was
generally agreed upon and is used since []. Nowadays,
ballistic devices have been developed with electromagnetic
working mechanisms.
Users and investigators found out that aiming at the
most painful area was sucient or even superior to aiming
just at an anatomically given landmark which was iden-
tied by imaging. is procedure has consequently been
demonstrated to be superior and was termed “biofeedback”
[]. One well-known example is a double-blind, randomized
placebo-controlled study on ultrasound-guided fESWT for
plantar fasciitis [].
Actually, focusing by biofeedback is also the cornerstone
for myofascial trigger point ESWT []. However, the treat-
ment of bone lesions like nonunions and osteochondrosis
dissecans still needs image guided application, for example,
by uoroscopy.
3.5. Growth Plates? In an experimental study on proximal
rat tibiae, dysplastic lesions could be identied following
high energy fESWT ( kV,  shock waves) []. As a
consequence from this study, ESWT was regarded to be
contraindicated in a juvenile population [].
Only two years later, another animal study was published
demonstrating no negative histological dierences compar-
ingfESWTeectwiththeuntreatedcontralateralfemoral

BioMed Research International
head of immature rabbits []. Another experimental rabbit
study was published in German language. e investiga-
tors applied  focused impulses (. mJ/mm2)whichis
comparable to a high fESWT in a human bone application.
Obviously, these two papers were underestimated in the
scientic world []. For rESWT, a recently published rat
experiment could detect “no negative eects” when  or
 impulses of  bar were applied to the immature rat knees
[].
Even if initially mentioned anecdotally already in 
[]itwasonlyrecentlywhentherstclinicalcaseseries
reported both safety and eectiveness when Osgood Schlatter
or Sever’s diseases were treated by using rESWT [, ].
3.6. Acute Injuries? When introducing musculoskeletal
ESWT, it was declared to be indicated for chronic injuries.
e reason for this was that in general a new treatment
modality should provide evidence before being spread out
to the public, and, as long as the evidence is missing, it
should be recommended only for patients, who already have
been treated by other options. is means that three months
of conservative treatment should have been performed
without success before ESWT is indicated as an alternative
to operative treatment [, ]. Extensive technical, manpower,
and time requirements have been advocated as rationales for
this limitation []. Additionally, economic factors limited
the musculoskeletal ESWT application. Consequently,
most research was traditionally made for conservatively
pretreated injuries with a history of more than three months.
International shock wave societies still consider only
nonacute pathologies (http://www.digest-ev.de/leitlinien/).
With the advent of cheaper and more exible ESWT
devices, this rule has been broken. For instance, in acute
and operatively treated long bone fractures high energy
fESWT eectively reduced the number of nonunions [].
Contrary to this, in a randomized controlled study rESWT
treatment was inferior to stretching for plantar fasciitis
patients when patients were not pretreated and complained
about symptoms under six weeks [].
IfESWTcanberelevanttoeectivelytreatacutemuscu-
lar or tendon strains is currently not known and respective
research is needed.
3.7. Tendinopathies with Extraosseous Calcication. Histor-
ically, only mechanical (and not biologic) ESWT eects
were regarded as relevant in medicine. At the transmission
through tissues with similar acoustic properties (so tissue)
a minor amount of energy is released. It was assumed that
the resulting mechanical eect is negligible. In contrast, high
acoustic impedance dierences exist between cortical bone
(. ×6kg/m2s)andsotissue(e.g.,muscle=.×
6kg/m2s). ESWT consequently releases a large amount of
mechanical energy at the interface. is concept was the
rationale not only to treat kidney stones but also to treat
so tissue calcications []. Initially, a real destruction of
bonewasnotdetectedasaresultfromESWT[],but
later experimental research demonstrated a dose-dependent
induction of cortical fractures and periosteal detachment
[]. Relevant acoustic impedance dierences exist also at the
interface between tendon and bone. erefore, well-dened
insertional tendinopathies like tennis elbow and plantar
fasciitis were thought to be also eligible for ESWT treatment
specically when combined with a spur [].
ese treatment principles were held until the invention
of the rESWT with a completely dierent technology. Histor-
ically, the main dierences between fESWT and rESWT are
as follows: (a) principle of generation = pneumatic rESWT
versus electrohydraulic, piezoelectric, or electromagnetic
fESWT, (b) wavelength = . to . m (rESWT) versus
. mm (fESWT), and (c) maximum pressure =  (rESWT)
versus – (fESWT) MPa and penetration depth = – cm
(rESWT) versus – cm (fESWT) []. Nowadays, there are
also ballistic devices available with electromagnetic working
mechanisms accelerating the projectile to hit the applicator.
Clinically most important thing is that the maximum energy
in rESWT is delivered at the interface between the applicator
head of the device and the skin and diminishes its energy
inside the treated tissue by the square of the penetration depth
[].
As a result, rESWT was applied to tendon lesions, fea-
tured by their immediately subcutaneous localization and by
a large area of injured tissue. Midportion Achilles tendinopa-
thy and patellar tendinopathy full these criteria and have
been demonstrated to be an indication for rESWT [, ,
]. Based on current evidence, we are unable to prefer
fESWT or rESWT for musculoskeletal so tissue injuries
[, ]. Conicting evidence exists from the results of two
studies that directly compared fESWT to rESWT in plantar
fasciitis and patellar tendinopathy patients [, ]. FESWT
revealed moderately superior results compared to rESWT
in plantar fasciitis, while no dierence was demonstrated
between the two applications regarding patellar tendinopathy
[, ].
3.8. ree Sessions Only? e number of required treatment
sessions is a relevant parameter in principle. Recently, system-
atic research recommends “three treatment sessions at -week
intervals, with  impulses per session and the highest
energy ux density the patient can tolerate” []. However,
historical reports do not adequately address that detail [,
]. Analogue to and derived from the lithotripsy nonunion
fractures have been treated with high energy predominantly
in one session. e reason for this procedure is most probably
based upon the intensive eort required by anesthesia and
uoroscopy. For the so tissue conditions a wide range ( to
) of treatment sessions was initially instructed [, ]. e
need of standardization of treatment regimens in randomized
controlled trials established one to three ESWT sessions at
weekly intervals as a standard clinical practice regardless of
the underlying pathology [, , , , , –].
Recently, there have been a few reports which retrospec-
tively addressed the number of rESWT sessions needed to
treat so tissue pathologies such as trigger digits, symp-
tomatic calcied shoulder tendinopathy, and plantar fasciitis.
ese studies revealed that pretreatment symptom duration
was signicantly correlated with the number of rESWT
sessions applied []. Additionally, there is evidence that
there is a dose-related ESWT eect with lower energy ux

BioMed Research International 
densities [mJ/mm2] requiring more treatment sessions to
obtain the same eect [].
Discussion is still going on about which parameters or
which combination of parameters should be used to maxi-
mize the eect of ESWT treatment for a specic indication.
In this context, it has to be mentioned that comparability of
studies should not be reduced on one single parameter (e.g.,
energy ux density).
In clinical practice, ESWT is rarely used as a monother-
apy. Strategic loading and/or exercises are usually prescribed
in addition to shock waves, a fact that in general RCTs have
not adequately addressed. An individualized intervention
should be considered depending initially on the type and
characteristics of the pathology [].
4. Discussion
e most important nding of this review is that all historical
paradigms as set for musculoskeletal ESWT in  did not
withstand the technical and clinical developments over the
last  years. e initial phase of the musculoskeletal ESWT
was driven by side eect research in context with lithotripsy
investigation and the rst orthopedic applications have been
performed by urologists []. Principles which were already
known from more than two million lithotripsies in men and
from respective animal studies were transferred and adapted
to musculoskeletal indications.
At the beginning of the musculoskeletal shock wave age
it was thought that the higher the energy is, the better
theoutcomewouldbe.Forsotissuepathologiesitwas
early realized that lower ESWT intensities are able to induce
tissue regeneration instead of necrotic reactions []. e
pain resulting from the ESWT is clearly depending on the
energy intensity [] but clinical focusing was shown to
improve the treatment results especially when performed
without local anesthesia [, ]. Specic ESWT devices for
musculoskeletal conditions were produced. Further reduc-
tion of the applied energy was delivered with the rESWT
technology. So and over the years, devices became much more
exible/mobile and had reduced volume, weight, and costs.
ere are an increasing number of high quality ESWT
studies for musculoskeletal conditions published in the liter-
ature. It can be summarized without exaggeration that ESWT
isthebestanalyzedtreatmentmodalityintheorthopedic
eld. is statement includes also operative interventions. A
recent systematic musculoskeletal ESWT review concludes
that there is more need for high level studies []. But the
question to be answered in future is not if ESWT works
but rather which treatment protocol and parameters are the
best for specic and well described conditions []. Research
nallyhastofollowclinicalpractice,wheretreatmentproto-
cols are individualized.
Until now, clinical ESWT research is aiming exclu-
sively at detecting the success of ESWT applied following
a standardized protocol. e question, however, if ESWT is
similarly eective in each stage of a given musculoskeletal
indication is completely unanswered up to date. For instance,
a “tendon pathology continuum model” has been described
[]. Derived from this, tendinopathy is “no longer a ‘one size
ts all’ diagnosis” []. It is to expect that dierent stages of a
given pathology will respond dierently to ESWT. Moreover,
monotherapies are rarely used in clinical practice. Given the
former, future randomized controlled work should focus on
assessing and comparing more realistic treatment protocols.
5. Conclusion
With the exception of bone related conditions, modern
musculoskeletal ESWT is performed with energy below
. mJ/mm2and without anesthesia. e size of the tissue
area to be treated can be small or large. “Biofeedback”
is superior to imaging guided focusing. ESWT application
in apophyseal osteochondral lesions in patients with open
growth plates seems to be promising and safe. ESWT pro-
tocols should be adapted to the stage and chronicity of the
treated pathology.
Competing Interests
Heinz Lohrer received fees for lecturing from Storz Medical
AG, T¨
agerwilen, CH. Employment of Tanja Nauck was
partially paid by Storz Medical AG, T¨
agerwilen, CH.
Acknowledgments
e authors are grateful to Ms. Grainne Mc Ginley for
her valuable help in language editing of the paper as a
native English speaker. e authors are grateful to Storz
Medical, Lohstampfestrasse ,  T¨
agerwilen, Switzerland,
for funding the open access publication article processing
charge.
References
[] P. Novak, “Physics: F-SW and R-SW. Basic information on
focused and radial shock wave physics,” in Multidisciplinary
Medical Applications, H. Lohrer and L. Gerdesmeyer, Eds.,
pp. –, Level  Buchverlag Daniela Bamberg, Heilbronn,
Germany, st edition, .
[] C. Chaussy, W. Brendel, and E. Schmiedt, “Extracorporeally
induced destruction of kidney stones by shock waves,” e
Lancet,vol.,no.,pp.–,.
[] J. Gra, K.-D. Richter, and J. Pastor, “Eect of high energy shock
waves on bony tissue,” Urological Research,vol.,pp.–,
.
[] G. Haupt, “Use of extracorporeal shock waves in the treatment
of pseudarthrosis, tendinopathy and other orthopedic diseases,”
e Journal of Urology, vol. , no. , pp. –, .
[] J.D.Rompe,C.J.Kirkpatrick,K.K¨
ullmer, M. Schwitalle, and O.
Krischek, “Dose-related eects of shock waves on rabbit tendo
Achillis. A sonographic and histological study,” e Journal of
Bone & Joint Surgery—British Volume,vol.,no.,pp.–
, .
[]G.P.Dahmen,R.Franke,V.Goncharsetal.,“DieBehand-
lung knochennaher Weichteilschmerzen mit Extrakorporaler
Stoßwellentherapie (ESWT). Indikation. Technik und bisherige
erapie,” in Die Stoßwelle—Forschung und Klinik, C. Chaussy,
F.Eisenberger,D.Jochum,andD.Wilbert,Eds.,pp.–,
Attempo, T ¨
ubingen, Germany, .

BioMed Research International
[] H. Lohrer, J. Sch¨
oll, and S. Arentz, “RSWT-schmerztherapie in
der orthop¨
adie und sportmedizin. Entwicklung und einsatz,” in
Extrakorporale Stoßwellentherapie,L.Gerdesmeyer,Ed.,pp.–
, Books on Demand, Norderstedt, Germany, .
[] G. Dahmen, G. Haupt, J. D. Rompe, M. Loew, J. Haist,
and R. Schleberger, “Standortbestimmung der arbeitsgruppe
‘orthop¨
adische stoßwellenbehandlungen’,” in Die Stoßwelle—
Forschung und Klinik,C.Chaussy,F.Eisenberger,D.Jocham,
andD.Wilbert,Eds.,pp.–,AttemptoVerlag,T
¨
ubingen,
Germany, .
[] P. Novak, “Physics: F-SW and R-SW. Basic information on
focused and radial shock wave physics,” in Multidisciplinary
Medical Applications, H. Lohrer and L. Gerdesmeyer, Eds.,
pp. –, Level  Buchverlag Daniela Bamberg, Heilbronn,
Germany, .
[] G. Haupt, R. Diesch, T. Straub et al., “Radiale stoßwell-
entherapie beim fersensporn (Fasciitis plantaris),” Der Niederge-
lassene Chirurg,vol.,no.,pp.–,.
[] C. B. Foldager, C. Kearney, and M. Spector, “Clinical application
of extracorporeal shock wave therapy in orthopedics: focused
versus unfocused shock waves,” Ultrasound in Medicine and
Biology, vol. , no. , pp. –, .
[] C. Speed, “A systematic review of shockwave therapies in so
tissue conditions: focusing on the evidence,” British Journal of
Sports Medicine,vol.,no.,pp.–,.
[]M.Delius,F.Ueberle,andS.Gambihler,“Destructionof
gallstones and model stones by extracorporeal shock waves,”
Ultrasound in Medicine and Biology,vol.,no.,pp.–,
.
[] W. Folberth, H. Krause, and T. Reuner, “Stoßwellenmeßtechnik
in der Lithotripsie: Historie und Ausblick,” in Die Stoßwelle—
Forschung und Klinik,C.Chaussy,F.Eisenberger,D.Jocham,
andD.Wilbert,Eds.,pp.–,Attempto,T¨
ubingen, Germany,
.
[] G. Haupt and M. Chvapil, “Eect of shock waves on the healing
of partial-thickness wounds in piglets,” Journal of Surgical
Research,vol.,no.,pp.–,.
[] L. Gerdesmeyer, M. Henne, M. G¨
obel, and P. Diehl, “Physical
principles and generation of shockwaves,” in Extracorporeal
Shockwave erapy,L.GerdesmeyerandL.S.Weil,Eds.,pp.–
,DataTracePublishingCompany,Towson,Md,USA,.
[] H. Gollwitzer, A. Saxena, L. A. DiDomenico et al., “Clinically
relevant eectiveness of focused extracorporeal shock wave
therapy in the treatment of chronic plantar fasciitis: a random-
ized, controlled multicenter study,” e Journal of Bone and Joint
Surgery—American Volume,vol.,no.,pp.–,.
[] L. Gerdesmeyer, C. Frey, J. Vester et al., “Radial extracorporeal
shock wave therapy is safe and eective in the treatment of
chronic recalcitrant plantar fasciitis: results of a conrmatory
randomized placebo-controlled multicenter study,” e Amer-
ican Journal of Sports Medicine,vol.,no.,pp.–,
.
[]H.Lohrer,T.Nauck,N.V.Dorn-Lange,J.Sch
¨
oll, and J. C.
Vester, “Comparison of radial versus focused extracorporeal
shock waves in plantar fasciitis using functional measures,” Foot
and Ankle International,vol.,no.,pp.–,.
[] H. Lohrer, J. Sch¨
oll, and S. Arentz, “Achilles tendinopa-
thy and patellar tendinopathy. Results of radial shockwave
therapy in patients with unsuccessfully treated tendinoses,”
Sportverletzung-Sportschaden, vol. , no. , pp. –, .
[] J. D. Rompe, B. Nafe, J. P. Furia, and N. Maulli, “Eccentric
loading, shock-wave treatment, or a wait-and-see policy for
tendinopathy of the main body of tendo Achillis: a randomized
controlled trial,” e American Journal of Sports Medicine,vol.
,no.,pp.–,.
[] K.H.E.Peers,R.J.J.Lysens,P.Brys,andJ.Bellemans,“Cross-
sectional outcome analysis of athletes with chronic patellar
tendinopathy treated surgically and by extracorporeal shock
wave therapy,” Clinical Journal of Sport Medicine,vol.,no.,
pp.–,.
[] H.vanderWorp,J.Zwerver,M.Hamstra,I.vandenAkker-
Scheek, and R. L. Diercks, “No dierence in eectiveness
between focused and radial shockwave therapy for treating
patellar tendinopathy: a randomized controlled trial,” Knee
Surgery, Sports Traumatology, Arthroscopy,vol.,no.,pp.
–, .
[] C.Schmitz,N.B.M.Cs
´
asz´
ar,S.Milzetal.,“Ecacyandsafetyof
extracorporeal shock wave therapy for orthopedic conditions:
a systematic review on studies listed in the PEDro database,”
British Medical Bulletin,vol.,no.,pp.–,.
[] M. Gleitz and K. Hornig, “Trigger points—diagnosis and
treatment concepts with special reference to extracorporeal
shockwaves,” Orthopade,vol.,no.,pp.–,.
[] H. Everke, “ years of experience of acupuncture with shock
waves,” Deutsche Zeitschri f¨
ur Akupunktur,vol.,no.,pp.
–, .
[] R. Schultheiss, “Stoßwellen-Technologie in Orthop¨
adie und
Unfallchirurgie,” in Die Stoßwelle. Forschung und Klinik,C.
Chaussy, F. Eisenberger, D. Jocham, and D. Wilbert, Eds., pp.
–, Attempto, T¨
ubingen, Germany, .
[] M. Haake, M. Buch, C. Schoellner et al., “Extracorporeal
shock wave therapy for plantar fasciitis: randomised controlled
multicentre trial,” British Medical Journal,vol.,no.,pp.
–, .
[] R. Buchbinder, R. Ptasznik, J. Gordon, J. Buchanan, V. Prabaha-
ran, and A. Forbes, “Ultrasound-guided extracorporeal shock
wave therapy for plantar fasciitis: a randomized controlled trial,”
eJournaloftheAmericanMedicalAssociation, vol. , no. ,
pp.–,.
[] J. D. Rompe, A. Meurer, B. Nafe, A. Hofmann, and L.
Gerdesmeyer, “Repetitive low-energy shock wave application
without local anesthesia is more ecient than repetitive low-
energy shock wave application with local anesthesia in the
treatment of chronic plantar fasciitis,” Journal of Orthopaedic
Research,vol.,no.,pp.–,.
[] G. Labek, V. Auersperg, M. Ziernhold, N. Poulios, and N.
Bohler, “Inuence of local anesthesia and energy level on the
clinical outcome of extracorporeal shock wave-treatment of
chronic plantar fasciitis,” Zeitschri f¨
ur Orthop¨
adie und ihre
Grenzgebiete,vol.,no.,pp.–,.
[] J. P. Furia, “High-energy extracorporeal shock wave therapy
as a treatment for insertional achilles tendinopathy,” American
Journal of Sports Medicine,vol.,no.,pp.–,.
[] W. Schaden, R. Mittermayr, N. Haner, D. Smolen, L.
Gerdesmeyer, and C.-J. Wang, “Extracorporeal shockwave ther-
apy (ESWT)—rst choice treatment of fracture non-unions?”
International Journal of Surgery,vol.,pp.–,.
[] T. Klonschinski, S. J. Ament, T. Schlereth, J. D. Rompe, and
F. Birklein, “Application of local anesthesia inhibits eects of
low-energy Extracorporeal Shock Wave Treatment (ESWT) on
nociceptors,” Pain Medicine, vol. , no. , pp. –, .
[] A. Sems, R. Dime, and J. P. Iannotti, “Extracorporeal shock
wave therapy in the treatment of chronic tendinopathies,”

BioMed Research International 
JournaloftheAmericanAcademyofOrthopaedicSurgeons,vol.
,no.,pp.–,.
[] L. D. Yeaman, C. P. Jerome, and D. L. McCullough, “Eects of
shock waves on the structure and growth of the immature rat
epiphysis,” e Journal of Urology,vol.,no.,pp.–,
.
[] K. N. Van Arsdalen, S. Kurzweil, J. Smith, and R. M. Levin,
“Eect of lithotripsy on immature rabbit bone and kidney
development,” e Journal of Urology,vol.,no.,pp.–
, .
[] K. Nassenstein, I. Nassenstein, and R. Schleberger, “Eects
of high-energy shock waves on the structure of the imma-
ture epiphysis—a histomorphological study,” Zeitschri f¨
ur
Orthopadie und ihre Grenzgebiete,vol.,no.,pp.–,
.
[] Z.Oztemur,H.Ozturk,S.Ozyurek,C.Kaloglu,U.H.Golge,and
O. Bulut, “e long-term eects of extracorporeal shock waves
on the epiphysis of the adolescent rat,” Journal of Orthopaedic
Science, vol. , no. , pp. –, .
[] R. Schleberger, “Anwendung der extrakorporalen Stoßwelle am
St¨
utz-und Bewegungsapparat im mittelenergetischen Bereich,”
in Die Stoßwelle. Forschung und Klinik, C. Chaussy, F. Eisen-
berger,D.Jocham,andD.Wilbert,Eds.,pp.–,Attempto
Ve rl a g , T ¨
ubingen, Germany, .
[] H.Lohrer,T.Nauck,J.Sch¨
oll, J. Zwerver, and N.Malliaropoulos,
“Extracorporeal shock wave therapy for patients suering
from recalcitrant osgood-schlatter disease,” Sportverletzung-
Sportschaden,vol.,no.,pp.–,.
[] H. Lohrer and T. Nauck, “Radial shock wave therapy for
patients with apophysitis calcanei,” Deutsche Zeitschri f¨
ur
Sportmedizin,vol.,no.,pp.–,.
[] C.-J. Wang, H.-C. Liu, and T.-H. Fu, “e eects of extracorpo-
real shockwave on acute high-energy long bone fractures of the
lower extremity,” Archives of Or thopaedic and Trauma Surgery,
vol. , no. , pp. –, .
[] J. D. Rompe, A. Cacchio, L. Weil Jr. et al., “Plantar fascia-specic
stretching versus radial shock-wave therapy as initial treatment
of plantar fasciopathy,” e Journal of Bone & Joint Surgery—
American Volume,vol.,no.,pp.–,.
[] M. Maier, J. Hausdorf, T. Tischer et al., “New bone formation
by extracorporeal shock waves. Dependence of induction on
energy ux density,” Orthopade,vol.,no.,pp.–,
.
[] J. D. Rompe, J. Furia, and N. Maulli, “Eccentric loading versus
eccentric loading plus shock-wave treatment for midportion
achilles tendinopathy: a randomized controlled trial,” American
Journal of Sports Medicine,vol.,no.,pp.–,.
[]S.Mani-Babu,D.Morrissey,C.Waugh,H.Screen,andC.
Barton, “e eectiveness of extracorporeal shock wave therapy
in lower limb tendinopathy: a systematic review,” e American
Journal of Sports Medicine,vol.,no.,pp.–,.
[] J. P. Furia, J. D. Rompe, A. Cacchio, A. Del Buono, and N.
Maulli, “A single application of low-energy radial extracor-
poreal shock wave therapy is eective for the management of
chronic patellar tendinopathy,” Knee Surgery, Sports Traumatol-
ogy, Arthroscopy,vol.,no.,pp.–,.
[] J. D. Rompe, J. Furia, and N. Maulli, “Eccentric loading
compared with shock wave treatment for chronic insertional
achilles tendinopathy. A randomized, controlled trial,” e
Journal of Bone & Joint Surgery—American Volume,vol.,no.
,pp.–,.
[] J. D. Rompe, A. Cacchio, J. P. Furia, and N. Maulli, “Low-
energy extracorporeal shock wave therapy as a treatment for
medial tibial stress syndrome,” American Journal of Sports
Medicine,vol.,no.,pp.–,.
[] A. Notarnicola, V. Pesce, G. Vicenti, S. Tafuri, M. Forcignan`
o,
and B. Moretti, “SWAAT study: extracorporeal shock wave
therapy and arginine supplementation and other nutraceuticals
for insertional achilles tendinopathy,” Advances in erapy,vol.
,no.,pp.–,.
[] C.-J. Wang, J.-Y. Ko, Y.-S. Chan, L.-H. Weng, and S.-L. Hsu,
“Extracorporeal shockwave for chronic patellar tendinopathy,”
American Journal of Sports Medicine,vol.,no.,pp.–,
.
[] J. Zwerver, F. Dekker, and G.-J. Pepping, “Patient guided Piezo-
electric extracorporeal shockwave therapy as treatment for
chronic severe patellar tendinopathy: a pilot study,” Journal of
Back and Musculoskeletal Rehabilitation,vol.,no.,pp.–
, .
[] N.Malliaropoulos,G.Crate,M.Meke,T.Nauck,H.Lohrer,and
N.Padhiar,“erecurrencerateofplantarfasciitisaerRadial
Extracorporeal Shock Wave erapy (rESWT) and the success
rate of the treatment: a retrospective study,” BioMed Research
International,Inpress.
[] S.-J. Lee, J.-H. Kang, J.-Y. Kim, J.-H. Kim, S.-R. Yoon, and K.-I.
Jung, “Dose-related eect of extracorporeal shock wave therapy
for plantar fasciitis,” Annals of Rehabilitation Medicine,vol.,
no. , pp. –, .
[] J. L. Cook and C. R. Purdam, “Is tendon pathology a contin-
uum? A pathology model to explain the clinical presentation of
load-induced tendinopathy,” British Journal of Sports Medicine,
vol.,no.,pp.–,.
[] J.Cook,“Tendinopathy:nolongera‘onesizetsall’diagnosis,”
British Journal of Sports Medicine,vol.,no.,article,.